Brain tuberculomas mimicking intracranial metastasis in a patient presenting with fits

Brain tuberculosis is still prevalent in many developing countries, especially Asian countries. Tuberculomas should always be considered in the differential diagnosis of enhancing intra-axial lesions of the brain. Brain tuberculomas can present in many different clinical and radiological patterns clinically like headache, fits, cranial nerve palsies and very rarely as brain tuberculomas. We describe the case of a 48 years old male patient presenting with persistent headache and fits, referred for workup of brain metastasis or primary brain neoplasm. On further imaging, it turned out to be multiple tuberculomas of brain which resolved on anti-tuberculous treatment along with symptoms relief

Ruptured Hydatid cyst in biliary tract

A lady aged 26 years reported with a 2 months history of fever, upper abdominal pain and weight loss. Her abdominal ultrasonographic scan revealed a complex cystic mass in left lobe of liver suggestive of hydatid cyst that was confirmed on magnetic resonance imaging of abdomen and magnetic resonance cholangiopancreatogram. With strong suspicion of a hydatid cyst, endoscopic retrograde cholangiogram was performed which confirmed the diagnosis. During the procedure, hydatid membranes protruding from the papilla were removed after sphincterotomy. She was put on albendazole 400 mg twice daily after the procedure and showed a remarkable clinical improvement

Endoscopic management of common bile duct stones experience at military hospital, Rawalpindi

To determine the characteristics of patients presenting with common bile duct [CBD] stones, to know the type of endoscopic therapy employed and to see procedure related complications. A descriptive study Palace and Duration of Study: The study was conducted in the Department of Gastroenterology of Military Hospital, Rawalpindi from Jan 2007 to Dec 2007. Adult patients with common bile duct stones who underwent endoscopic retrograde cholangiopancreatography [ERCP] enrolled in a consecutive manner. The procedure was done under sedation with midazolam and meperidine after informed and written consent. Patients data was obtained from the department and entered on a spread sheet to calculate percentages and frequencies .The data was analyzed using Statistical Package for Social Sciences [SPSS] version 10 to document the endoscopic procedures done and the procedure- related complications. Two hundred and twenty five patients underwent ERCP for evaluation and treatment of CBD stones. Mean age was 45 years with female to male ratio of 1.9: 1. Out of 225 patients, cannulation failed in 4 cases due to duodenal stenosis and 154 [70%] out of 221 cases of CBD stones mandated endoscopic treatment with balloon trail, basket extraction, placement of plastic biliary stent temporarily or use of mechanical lithotriptor. Duct clearance was achieved in 67% cases. Complication rate has been 9% with bleeding being the most common complication with no mortality. A duct clearance rate of over 67% was achieved with sphincterotomy combined with balloon trail, basket extraction and lithotripsy. Bleeding was the most common procedure- related complication. Very large CBD stones/ Mirrizi syndrome cases were referred for surgical intervention

Helicobacter pylori infection in patients with dyspeptic symptoms having normal endoscopy

To find out the frequency of Helicobacter pylori infection in the local population presenting with dyspeptic symptoms but having normal upper gastrointestinal endoscopic findings. This descriptive study was carried out in gastroenterology department of Military Hospital Rawalpindi. The study was conducted in the department of gastro intestinal of Military Hospital Rawalpindi from November 2004 to September 2005. Hundred cases of dyspepsia having normal upper gastrointestinal endoscopy were taken as study population. Although the gold standard for presence or absence of Helicobacter pylori infection is culture but in this study the diagnostic method used was histopathology of gastric antrum. The male and female ratio was 2:1. Majority of the patients were either 40 years of age or less, mean age being 40.52 [sd +/- 13.22]. The chief symptoms were pain epigastrium [46%] and upper abdominal discomfort [27%]. Helicobacter pylori gastritis was found in 51% of cases. We conclude that Helicobacter pylori infection is quite common in dyspeptic patients apparently having normal endoscopic gastric mucosal findings. Eradication therapy should be instituted in positive cases to avoid its long-term complications

Effects of combined interferon alpha and ribavirin therapy on thyroid functions in patients with chronic hepatitis C

To determine the frequency of thyroid dysfunction in patients of chronic hepatitis C during treatment with interferon alpha-2b and ribavirin therapy. A cohort study. Army Medical College and Military Hospital, Rawalpindi, from February 2006 to January 2007. One hundred and sixty seven non-cirrhotic chronic hepatitis C patients were grouped into treatment group [n=107] and control group [n=60] awaiting treatment. Baseline serum[s.] Alanine Transferase [ALT] and S. Aspartate Transferase [AST] were measured by IFCC method. Serum Thyroid Stimulating Hormone [S. TSH], serum free thyroxine [S. Free T4] and serum total triiodothyronine [S.T3] level were determined by chemiluminescence. Study group patients underwent 24 weeks IFN and ribavirin therapy and were followed-up for thyroid dysfunction at weeks 0, 12 and 24. Control group patients underwent the same tests at weeks 0, 12 and 24. Statistical analysis was done on SPSS 15. Out of 107 patients of treatment group, 20 patients [18.69%] developed thyroid dysfunction. Females were at higher risk with Relative Risk [RR] of 11.25 and Attributable Risk [AR] of 91%. Hypothyroidism was more common than hyperthyroidism. Interferon-alpha and ribavirin therapy induces thyroid dysfunction in chronic hepatitis C patients. Hypothyroidism was more common. Females are at a higher risk of developing thyroid dysfunction

Indications for endoscopic ultrasound and diagnosis on fine needle aspiration and cytology

To determine common indications for requesting Endoscopic Ultrasound [EUS] and to describe the diagnosis made after endoscopic ultrasound/Fine-Needle Aspiration and Cytology [FNAC] during two years at a tertiary gastrointestinal unit. Cross-sectional descriptive study. The study was carried out in Gastrointestinal Department of Military Hospital, Rawalpindi, from March 2006 to February 2008. One hundred and eighty nine patients who underwent EUS during study period at Military Hospital were included in the study. Patients too ill [hypoxemic/hypotensive] to undergo procedure safely and those with complete esophageal blockage at upper end by tumour not allowing scope/EUS probe to advance beyond were excluded. EUS was done with Olympus Exera EUS 160, linear or radial scope, as required. EUS findings were recorded against indications as enlarged lymph nodes, tumour, staging, normal or incomplete. Fine-Needle Aspiration [FNA] was done as per findings on EUS using 21-22 G needle. An on-site cytopathologist made the provisional cytopathological diagnosis. Final cytology/histopathology report was given after review of slides by consultant histopathologists at Armed Forces Institute of Pathology [AFIP], Rawalpindi, and were documented as tuberculosis, malignancy, chronic pancreatitis or reactive hyperplasia. Data was analyzed for documentation of patients' age, gender, common indications, findings on EUS/FNAC, using SPSS version 10. Percentages and frequencies were calculated for the presence of these above-mentioned variables. Of the 189 patients, 145 [77%] were male and 44 [23%] female. Age was 18-80 years [mean 49 years]. Major indications for referral were lymphadenopathy in 92 [49%], suspected growth pancreas in 57 [28%], growth of stomach in 20 [11%] and a heterogeneous group included esophageal, liver, retroperitoneal masses, rectal and other pathologies. Findings on EUS included lymphadenopathy in 76, mostly in sub-carina and AP window. Mass in pancreas was seen in 36, followed by stomach tumour in 17 and esophagus in 9. FNAC was done in 142 out of 189 patients. Final diagnosis out of 67 FNAC/histopathology of lymph nodes were tuberculosis in 26 and malignant lesions in 23. These included metastatic adenocarcinoma in 8, lymphoproliferative disorder in 7, metastatic squamous cell carcinoma in 5, small cell carcinoma in 2 and anaplastic in 1. Pancreatic tumours were adenocarcinoma in 16, poorly differentiated in 3 and neuroendocrine in 2. Stomach tumours were found in 11, and included lymphomas 5, GIST 3, carcinoids 2, metastatic choriocarcinoma 1 and adenocarcinoma in 1. Therapeutically, 3 celiac blocks and one pancreatic pseudocyst drainage was done. The main indication of EUS and pathology of mediastinal and celiac nodes were metastatic malignancy and tuberculosis. Pancreatic adenocarcinoma was another common cause for asking EUS

Comparison of diagnostic yield of AFB with sputum induction to spontaneous sputum examination in suspected pulmonary tuberculosis

To compare the diagnostic yield of AFB positivity with sputum induction to spontaneous sputum examination in suspected cases of pulmonary tuberculosis. Comparative study. Military Hospital, Rawalpindi, from January to December 2006. Sputum specimens were collected by both techniques from 164 patients with clinical and radiological suspicion of pulmonary tuberculosis admitted in medical wards. All specimens were examined for AFB smear and culture positivity. Sputum induction was done for 15-20 minutes with 3% sterile hypertonic saline solution by nebulization in all cases. Proportions were compared using Chi-square test. Among 164 patients, 32 patients [19.5%] were not expectorating spontaneously. Sputum induction was successful in 22 [68.75%] cases and AFB smear was positive in 03 [9.37%] and AFB culture was positive in 7 [21.8%] of these cases. One hundred and thirty two [80.5%] patients were already expectorating and both Day-1 [spontaneous] and Day-2 [induced] sputum samples were available. Day-1 [spontaneous] sputum specimens revealed AFB smear positive results in 20 [15.15%] patients, and AFB culture positive results in 24 [18.18%] patients. Smear positivity on Day-2 [induced] sputum samples was 21.21% [28] with 27.27% [36] culture positivity. In expectorating patients, AFB smear and culture positivity results remain comparable with spontaneous and induced sputum sampling. Sputum induction improves the diagnostic yield for AFB in patients unable to expectorate adequate sputum sample

Diagnostic evaluation of patients presenting with bleeding per rectum by colonoscopy

Rectal bleeding is a manifestation of lower gastrointestinal bleed, which means bleeding from a site distal to ligament of Treitz. Annual incidence of this problem has been estimated to be 20% and mortality as 11%. Patients complaining of haematochezia are suspected of having lower GI bleeding and proctosigmoidoscopy followed by colonoscopy is the examination of choice for diagnosis and treatment. Previous evidence suggested that in our country, frequencies of different aetiologies of lower GI bleed are different from the West. This study validated the previous findings. The Objective of this study was to determine the causes of rectal bleeding in adult patients at Military Hospital, Rawalpindi. One hundred and five adult patients with visible rectal bleed, irrespective of their gender were selected by non-probability convenient sampling from general medical OPD and general medical wards. Patients with suspected upper GI source of bleeding; haemorrhoidal bleed and acute infectious diarrhoea were excluded from the study. All patients were subjected to fibre-optic colonoscopy after necessary preparation and findings were recorded. Biopsies taken from suspected lesions were clinically indicated. Diagnosis was based on colonoscopic and histopathologic findings. A total of 105 patients [77 male and 28 female] with mean age 41.04 yrs were part of the study. Colonoscopy showed abnormal findings in 85 [84%] patients. The commonest diagnosis was ulcerative colitis, which was found in 48 [46%] patients. It was followed by colorectal carcinoma, 11 [10%] patients, and non-specific colitis, 9 [8%] patients. Other less frequent findings were colonic diverticuli, 7 [6%] patients, solitary rectal ulcer, 5 [4%] patients, colonic polyps in 3 [2.5%] patients and one case each of telangiectasia and Crohn's disease. Colonoscopy has very high diagnostic yield and would be recommended in the workup of patients presenting with bleeding per rectum. Ulcerative colitis was the leading cause of bleeding per rectum in this study; while infrequent findings of Crohn's disease, polyps and diverticuli indicate that these are uncommon in this region

Reactive thrombocytosis following acute infection and pancytopenia

A 15-year-old girl was admitted with a fifteen day history of high grade intermittent fever with chills along with passage of loose watery stools, 6-8 times/day, not containing any blood or mucus. On examination, she was thin lean girl, who was markedly pale but fully conscious and well oriented. Initial laboratory investigations were suggestive of pancytopenia with haemoglobin of 4.7 g/dl; white cell count 1.3x10[9]/1 and a platelet count of 13x10[9]/1. Mean corpuscular volume [MCV] was 99.3 fl, while peripheral blood film showed macrocytosis, anisocytosis and poikilocytosis. Erythrocyte sedimentation rate was 120 mm at the end of 1st hr and C-reactive proteins were elevated. Her ALT was raised to 70 U/L, bilirubin and alkaline phosphatase were with in normal limits. Serology for Hepatitis B and C was negative. Reticulocyte count was 1%. Her bone marrow aspiration and trephine biopsy showed hypercellularity with megaloblastic as well as dyserythroblastic cells suggesting a differential diagnosis of either myelodysplasia secondary to some infections or aplastic anemia in evolution. Injection Trividox B1, B6, and B12] and folic acid were also added to treatment because her serum B12 level was found to be at lower normal limit. Complete picture repeated 15 days showed a platelet count of 1610 x 10[9]/L. This high countindicated reactive thrombocytosis confirming bone marrow recovery. The probable cause of this reactive thrombocytosis was recovery from acute infection or Vit B12 supplementation

Nutritional profile and inflammatory status of stable chronic haemodialysis patients at Nephrology Department, Military Hospital Rawalpindi

Protein-energy malnutrition [PEM] is common in the haemodialysis population. Identification and management of these patients can result in significant reduction in morbidity and mortality. Aim of the study was to find the prevalence of PEM in otherwise stable haemodialysis patients at Military Hospital Rawalpindi at a single point in time with the help of established biochemical and physical markers. Height, dry weight and body mass index [BMI] were recorded for 64, stable, 14-75 year-old patients who were on haemodialysis for >/= 3 months. Blood samples were drawn [pre-dialysis] for complete blood count, serum C-reactive protein, serum total protein, serum albumin and serum Creatinine. Ideal body weights and BMI were obtained from Pakistan Army Selection and Recruitment standards. Out of 64 patients 43 [67%] were males. Mean age was 44.5 +/- 14.3 yr. Mean haemoglobin was 8.84 +/- 2 g/dl. Fifty-seven patients [89%] had haemoglobin

Risk of transmission of hepatitis-B and C viruses in upper gastrointestinal endoscopy-a hospital based study

A study was carried out at Gastroenterology department Military Hospital, Rawalpindi, from 6th June to 24th October 2002, to assess the risk of upper gastrointestinal endoscopic procedure as a route of transmission of HBV and HCV. One hundred consecutive patients reporting for endoscopy at Gastroenterology department, MH, Rawalpindi, fulfilling the inclusion and exclusion criteria were selected. Their base-line HBV and HCV status were assessed prior to endoscopy. They were then recalled after 04 months to re-assess the HBV and HCV status. Two patients [2%] tested positive for HBsAg, and none for Anti HCV antibodies, after 04 months of the procedure. One of the HBsAg positives had a history of unchecked blood transfusion after the endoscopy. Endoscopy is a very safe procedure provided strict disinfection techniquse are followed. However, staff and patient education regarding preventive methods against HBV and HCV remains the cornerstone in avoiding their transmission

Transverse testicular ectopia

We present a case of Transverse testicular ectopia of the right testis that presented out surgical out patient department with left inguinal hernia and an impalpable testis in the right sccrotum. Patient was operated. Left herniotomy was performed and right testis was found in the left inguinal canal which was brought to the right scrotum and anchored through suprapubic subcutaneous tunnel

Efficacy of combined interferon alpha and ribavirin therapy in patients of chronic hepatitis C

This study was carried out to determine the efficacy of combined interferon alpha and ribavirin therapy in patients of chronic hepatitis C. This study was conducted at Military Hospital Rawalpindi and Army Medical College, Rawalpindi from January 2006 to Feb 2007. One hundred and sixty seven non cirrhotic chronic hepatitis C patients were studied. The patients were grouped into study group [n=107] and control group [n=60]. The patients had persistently raised serum aminotransferase [ALT], positive HCV antibodies by 3[rd] generation ELISA, positive HCV RNA by polymerase chain reaction. Study group patients had positive histopathological findings on liver biopsy on basis of Knodell histopathological index [HPI]. At weeks 0, 12 and 24, blood samples were taken for the assay of serum alanine transferase [ALT] and serum, aspartate transferase [AST] levels in both the groups. Study group patients underwent 24 weeks Interferon and Ribavirin combination therapy and subsequently followed up for the response to treatment by the assay of HCV RNA by polymerase chain reaction at weeks 24. Control group included the patients without treatment plan but they also underwent screening for the same liver function tests. Patients of chronic hepatitis C [80 males and 27 females] had age range 18-48 years. After 24 weeks of INF and ribavirin therapy, 86% patients showed favourable response to treatment manifested by negative HCV RNA polymerase chain reaction. Treatment with Interferon and ribavirin combination therapy for 24 weeks produces significant virological response in patients of chronic hepatitis C at the end of treatment

Types of anemia in patients with hemoglobin less than 10g/dl

To find out different types of anemia in patients with hemoglobin less than 10 g/dl in relation to age and sex in Rawalpindi region. A descriptive study. This study was carried at Military Hospital Rawalpindi and Armed Forces Institute of Pathology Rawalpindi from February 1997 to March 1998. Patients above 12 years of age from both sexes with hemoglobin less than 10g/dl were randomly selected for the study. Patients suffering from other hematological diseases such as leukemia, myeloproliferative/lymphoproliferative disorders were excluded. Total 208 anemic patients were included in the study. History and physical findings were recorded. Laboratory investigations such as blood complete counts, red blood cells morphology, bone marrow examination and other relevant investigations where indicated for diagnosis were carried out. Iron deficiency anemia was found to be the most common type [n=68, 32.69%] of anemia. In 12-45 years age group, iron deficiency anemia was found in 54 [35.29%] cases, followed by megaloblastic anemia in 23 [15.03%] cases. In age group 46 years and above, megaloblastic anemia was found in 16 [29.09%] cases followed by iron deficiency anemia in 14 [25.45%] cases. Nutritional anemias are the most common types of anemia in our population. Iron deficiency is the commonest type present in females of reproductive age. Megaloblastic anemia was the commonest types of anemia in individuals of either sex over 46 years of age

Spontaneous bacterial peritonitis

To evaluate the prevalence, diagnostic criteria and microbial spectrum of spontaneous bacterial peritonitis [SBP] and its variants in cirrhotic patients with ascites. A hospital based prospective study carried out in cirrhotic patients with ascites. The study was conducted in the Department of Medicine Military Hospital Rawalpindi during October 2000 to March 2002. One hundred and eighty consecutive patients of cirrhotic liver between the ages of 20-65 years presenting with ascites reporting to outdoor patient department of Military Hospital Rawalpindi were included in the study. The diagnosis of cirrhosis was made on history, clinical examination and the ultrasonographic findings. These patients were subjected to ascites fluid tap and the patients were divided into SBP and non-SBP groups in the light of results of ascitic fluid routine examination and culture. The SBP group was further categorized into culture positive SBP, culture ne gative neutrocytic ascites [CNNA] and bacterascites [BA] on the basis of culture results and total leukocyte count, absolute polymorphonuclear leukocyte count per cubic mm of ascitic fluid. The study included 144 males and 36 females having cirrhosis with ascites. The mean age of these patients was 52.32 +/- 7.87 years. On the basis of routine examination and culture of tapped ascitic fluid from these cases 57 of 180[31.66%] patients were diagnosed to have SBP or its variants, In addition to classic SBP in 18[31.58%] patients, its variants namely culture negative neutrocytic ascites and bacterascites were detected in 37[64.92%] and two [3.5%] cases respectively. E. coli was the most frequently cultured organism. It was isolated in 12 cases of SBP [60%]. In 4 cases [20%] Klebsiella was cultured whereas Proteus mirabilus and Streptococcus were reported in two cases [10%] each. This study indicates that spontaneous bacterial peritonitis is common and potentially fatal complication in cirrhotic patients with ascites. E. coli is the most frequent offending organism

Hepatitis A virus infection - shifting epidemiology

To determine the age distribution in HAV infection and seasonal variations in the prevalence of acute viral hepatitis caused by hepatitis A virus. A descriptive study. The study was carried out on the patients reporting at Virology Department, Armed Forces Institute of Pathology [AFIP], Rawalpindi, for determination of hepatitis A virus [HAV] IgM antibody, from July 2003 to June 2004. Altogether 626 patients with clinical suspicion of hepatitis A virus infection were referred to AFIP Rawalpindi for this test. Blood samples were collected and sera were separated and transferred to plastic aliquots that were stored at -20oC in a retrievable fashion until utilized in testing. The testing for ant-HAV IgM was carried out with the help of a commercial Enzyme Linked Immunosorbant Assay [ELISA] using reagent kits of DiasSorin [Germany] for HAV IgM antibodies. The HAV IgM positive rate was 40.57% [252/626]. Those tested included the sporadic cases as well as the patients from outbreak in two schools of Nowshera cantonment. The age of patients testing positive for HAV IgM, ranged from 03 to 27 years. There was a statistically significant seasonal difference in rate of positivity in different months of the calendar year. An outbreak of HAV infection was seen in the children of two neighboring schools of a cantonment, in which 44 children in different classes developed clinical jaundice. HAV infection occurs in a significant proportion of young people with a clinical suspicion of HAV infection. There is a changing trend of developing hepatitis A in the age beyond 18 years and in outbreaks, which was not there in our patients previously due to universal immunity found against HAV by the age of 18. It was because of chances of consumption of polluted food

Hyperventilatory capacity - a predictor of altitude sickness

The aim of the study was to document link between hyperventilatory capacity and risk for developing acute mountain sickness [AMS]. This study was carried out at Karakorum Mountain ranges [Northern areas of Pakistan] from March till July 2004. 54 healthy male subjects were enrolled in this study. Arterial oxygen saturation [SpO[2]] of the subjects was measured by the pulse oximeter at rest and after 1 minute of voluntary hyperventilation at an altitude of 2833 meters. Symptoms of acute mountain sickness [AMS] were recorded on a questionnaire by using the Lake Louise consensus scoring system 24 hours after ascent to high altitude. Mean pre hyperventilation oxygen saturation [SpO[2]] was 94.07 + 0.26% whereas SpO2 after 01 minute of hyperventilation was 98.61 + 0.14% that was significantly increased [p<0.001]. The mean increase in percent oxygen saturation of hemoglobin after one minute of hyperventilation [hyperventilatory capacity] for the study group was 4.61 + 0.24% while the mean symptom score was 2.06 + 0.26. It was noted that 19 [35.2%] subjects did not develop AMS whereas 34[63.0%] subjects had mild AMS and only one subject developed moderate AMS. There was no case of severe AMS. The data reveals significant [P<0.01] association between hyperventilatory capacity and development of the symptoms of AMS [r= - 0.664]. It is evident that individuals with greater hyperventilatory capacity manifest less number of symptoms of mountain sickness. It is concluded that post hyperventilation increase in oxygen saturation at lower altitude may help to predict the susceptibility of subjects to develop high altitude sickness

Bilateral emphysematous pyelonephritis

A 63 year old male, known diabetic for 10 years and a known case of Ischemic Heart Disease for almost same duration, on regular treatment presented in a peripheral hospital with 4 days history of jerky movement of left half of body, fever, cough and urinary incontinence. Examination revealed bibasal crackles in chest; tenderness in right lumber region and upper motor neuron type weakness in left half of body. Investigations revealed Hb 15.1, TLC 17.8, platelet count of 28,000, numerous RBCs and Pus cells in urine. LFTs were normal. There was no ketonuria and DIC screen was negative. Serum urea and creatinine done on alternate days showed a rising trend with max serum urea 34.8 mmol/L and serum creatinine 1138 umol/L five days following admission. Hepatitis serology was negative. Culture of urine showed growth of Escherichia coli as well as candida species. CT scan Brain revealed right Parietal lobe infarct. USG Abdomen revealed air lucencies in subcapsular and cortical region of both kidneys suggesting bilateral emphysematous pyelonephritis. CT scan abdomen confirmed bilateral emphysematous pyelonephritis [R>L] with extension of air lucencies in perinephric spaces and prominence of gerota's fascia bilaterally. Right kidney was at the verge of bursting. Case was discussed with Urologist and Anesthetist but patient was unfit for surgery because of existing comorbid conditions. Aggressive conservative management was started including antibiotics [intravenous Tazocin] based on urine c/s and intravenous Fluconazole alongwith alternate